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 Table of Contents  
Year : 2020  |  Volume : 23  |  Issue : 4  |  Page : 236-241

Antimicrobial stewardship: Perception and familiarity of future prescribers in a tertiary health institution in Northern Nigeria

1 Department of Community Medicine, ABU, Zaria, Nigeria
2 Federal Medical Centre, Yola, Nigeria
3 Katsina State Ministry of Health, Katsina, Nigeria
4 Department of Community Medicine, Kaduna State University, Kaduna, Nigeria
5 Nigeria Field Epidemiology and Laboratory Training Program, Abuja, Nigeria

Date of Submission20-Nov-2018
Date of Decision24-Feb-2019
Date of Acceptance04-Sep-2020
Date of Web Publication23-Feb-2021

Correspondence Address:
Dr. Abdulhakeem Abayomi Olorukooba
Department of Community Medicine, ABU, Zaria
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DOI: 10.4103/smj.smj_62_18

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Background: Antimicrobial stewardship (AMS) is a coordinated program that promotes the appropriate use of antimicrobials. According to the World Health Organization, education of medical students on AMS is an integral part of antimicrobial resistance containment activities. The perception of undergraduate clinical medical students on AMS has not been studied in Nigeria recently. This study aims to identify the perception of AMS among medical students in Ahmadu Bello University (ABU) Zaria. Methodology: We conducted a cross-sectional survey on medical students in the 4th, 5th, and 6th years of study. A stratified sampling technique was employed. Open Data Kit for android was used to administer the questionnaire. Information on sociodemographics, perception of AMS, perception of the usefulness of AMS education as well as familiarity with the term AMS were collected from study respondents. Data were presented in frequency and percentages for categorical variables, while descriptive summary statistics were used for numeric variables. Results: Most of the respondents (96.2%) belonged to the age group of 20–29 years. The mean age (±standard deviation) of our respondents was 25.75 (±2.47) years. Only 34.6% were “very familiar“/”familiar” with the term “AMS.” Majority (89.2%) of the respondents did not have any knowledge about antimicrobials before entering medical school. The perception of AMS among medical students was generally good. Conclusion: Our respondents recognized the importance of judicious antibiotic use and would like more instructions on how to make rational use of antimicrobials. There is a need by authorities of the ABU medical school to revamp our clinical medical curriculum to include more AMS teaching so as to better equip our “future prescribers” on the appropriate use of antimicrobials.

Keywords: Antibiotics, antimicrobials, appropriate use, curriculum, rational use, stewardship, university

How to cite this article:
Olorukooba AA, Helda MI, Yahaya SS, Nwankwo B, Ahmadu L, Hamza KL. Antimicrobial stewardship: Perception and familiarity of future prescribers in a tertiary health institution in Northern Nigeria. Sahel Med J 2020;23:236-41

How to cite this URL:
Olorukooba AA, Helda MI, Yahaya SS, Nwankwo B, Ahmadu L, Hamza KL. Antimicrobial stewardship: Perception and familiarity of future prescribers in a tertiary health institution in Northern Nigeria. Sahel Med J [serial online] 2020 [cited 2021 Mar 4];23:236-41. Available from: https://www.smjonline.org/text.asp?2020/23/4/236/310027

  Introduction Top

Antimicrobials are the most widely prescribed group of medicines both at outpatient and inpatient care, and the irrationalities of their use are contributing a serious burden on health care expenditure.[1] Irrational use of antimicrobials has the potential to compromise the ability to treat many infections. Antimicrobial stewardship (AMS) in its simplest term means “taking care of these antimicrobials.” It helps to stem antimicrobial overuse and prevent antimicrobial resistance through an organized effort to educate and encourage prescribers of antimicrobials to follow evidence-based prescribing.[2] AMS program is created with the goals of improving clinical outcomes, promoting patient safety, reducing antimicrobial resistance, and reducing cost.[3]

Antimicrobial resistance has risen to such a degree that the Centers for Disease Control and prevention rang the alarm for developing an AMS program. In 2012, the Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society published a joint policy statement on AMS.[3] The Joint Commission has approved regulations which took effect on January 1, 2017, detailing that hospitals should have an AMS team consisting of infection preventionist (s), pharmacist (s), and a medical practitioner to write protocols and develop projects focused on the appropriate use of antimicrobials.[4] AMS is needed wherever antimicrobials are prescribed in human medicine.

Many studies have identified the educational needs of medical students in AMS.[5],[6],[7],[8] This is so as to make them prepared for their role as “future prescribers.” Physicians who are insufficiently prepared to make choices on antibiotic selection may use antibiotics inappropriately. The medical student has a professional and moral duty to learn about and practice good antimicrobial prescribing, which is the cornerstone of AMS.[9] The perception of AMS among undergraduate medical students in Nigeria has not been well studied. An understanding of their perception is important in order to plan and implement appropriate educational interventions that could improve their knowledge of appropriate use of antimicrobials which could ultimately help in making medical students better prepared for their role as “future prescribers.” This could go a long way in reducing the scourge of antimicrobial resistance. This study aims to determine the perception and familiarity of clinical medical students of Ahmadu Bello University (ABU) Zaria regarding AMS.

  Methodology Top

The study was conducted among clinical medical students of ABU Teaching Hospital (ABUTH). The total students' enrollment currently in the university's degree and subdegree programs is about 35,000, drawn from every state of the federation, Africa, and the rest of the world. Medical students in ABU come from different sociocultural background, ethnicity, and religion from across Nigeria and beyond. The university has about 1400 academic and research staffs and 5000 support staffs serving the university.[10] As at the time of this study, there were 668 medical students enrolled in ABU, out of which 370 were in preclinical and 298 were in clinical. At the time of the study, the 500-level medical students in ABU had 2 sets designated as A and B (due to administrative reasons). Pharmacology is being taught to the medical students in ABU in their 200, 400, and 500 levels of study. A cross-sectional, descriptive study was carried out among clinical medical students of ABU Zaria, and all clinical medical students of ABU Zaria willing to participate in the study were recruited into the study. Students who were away for posting outside the hospital were excluded.

Sample size (n) was calculated using the Leslie Fisher's formula for estimating single proportions in a population <10,000 for cross-sectional studies.[11] A prevalence of 51% from a previous study in the United States of America was used.[6] The estimated number of medical students in ABU was <10,000, and a correction factor was employed using the finite population correction formula below to derive the required sample size of 185 students (with the allowance of 10% for nonresponse).

A stratified sampling technique was used with proportional allocation to each stratum (level). In each level, simple random sampling was done using the balloting method to select eligible respondents. A class list was obtained from the class representative in each level. Using balloting, the required number was selected from each level. Based on proportion of students in the 400 level, 500 level A, 500 level B, and 600 level, the eligible participants selected were 61, 19, 35, and 70, respectively.

Open Data Kit (ODK) Collect version 1.9.1 installed on an android device, containing the questionnaire, was used to collect the data. A semi-structured questionnaire was designed. The questionnaire was adapted from similar studies.[6],[12],[13] The first part of the questionnaire obtained sociodemographic characteristics (age, sex, education, occupation, religion, and marital status) of the students interviewed. The second part contained questions related to perception of AMS. Both a 5-point Likert scale[14] and dichotomous answers were used. The questionnaire was given to an expert in the field of public health for face and content validity assessment. The questionnaire was also pretested among preclinical medical students, and appropriate modifications were made to the questionnaire after the pretest.

The clarity and completeness checkup of data collection formats was carried out before the actual data collection. The questionnaire was converted into an electronic form and uploaded into the ODK software on android devices for data collection. Questionnaires were self-administered, and participation was voluntary, anonymous, and without compensation. The researchers assured that anonymity was maintained, and human research ethical principles were followed. Before the administration of questionnaires, the background and intentions of the survey were explained, and students were encouraged to participate without any undue pressure. Verbal informed consent was obtained from all the participants after explaining the nature of the research.

The data obtained were extracted from the android devices and imported into and analyzed using IBM Statistical Product for Service Solutions (SPSS) software version 23.0 (Armonk, NY: IBM Corp.). Interpreted data were represented using Microsoft Office Word 2010 and in tables and charts where appropriate. Respondents' perception of AMS was scored based on the number of questions answered correctly. The perception of AMS was measured using 8 core questions on a five-point Likert scale system. The response categories on each item ranged from 1 (strongly disagree) to 5 (strongly agree). Frequencies and percentages were used to summarize categorical variables, while descriptive summary statistics such as means and standard deviation were used to describe numerical variables.

Ethical clearance was sought and obtained from the Research Ethics and Review Board of ABUTH. Verbal informed consent was obtained from each respondent. Confidentiality of the information was assured and privacy of respondents was maintained. Data collected were stored in a password-protected computer. Only the researchers had access to the computer that was used.

  Results Top

One hundred and eighty-five of the two hundred and ninety-eight clinical medical students in the 4th, 5th, and 6th years of medical study participated in the survey. A total of 185 questionnaires were administered, and all were filled, giving a response rate of 100%. Most of the respondents (96.2%) belonged to the age group of 20–29 years [Table 1]. The mean age (standard deviation) of our respondents was 25.75 (±2.47) years. Majority (89.2%) of the respondents did not have knowledge about antimicrobials before gaining admission into medical school [Figure 1]. Majority (67.6%) of the respondents perceived that antimicrobials were overused nationally [Table 2]. Most (99.5%) of the respondents also perceived that a strong knowledge of antimicrobials is important for their medical career [Table 2]. Only 34.6% were familiar with the term “AMS.” More than four-fifths (82.7%) of the respondents had the perception that medical schools should spend more time teaching appropriate use of antimicrobials at the clinical levels [Table 3]. Only 29 (15.7%) of the respondents perceived that their education regarding AMS was not useful [Table 4]. Respondents' mean perception score was 34.05 ± 2.63. There was no statistically significant association between the perception of AMS and sociodemographic characteristics of students [Table 5].
Figure 1: Knowledge regarding antimicrobials before entering medical school among respondents

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Table 2: Respondents' perception of antimicrobial stewardship

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Table 3: Respondents' perception of when medical school should teach appropriate use of antimicrobials

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Table 4: Respondents' rating of antimicrobial stewardship education

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Table 5: Relationship between perception and sociodemographic characteristics of respondents

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  Discussion Top

Our survey was anonymous and voluntary; this stimulated the participants to provide reliable answers rather than socially desirable answers. This survey was similar in design to some studies of medical students in the United States, India, and Bangladesh.[6],[7],[8] About two-thirds of the respondents were between the age ranges of 25 and 29 years. This is the common age group of clinical medical students in similar studies.[6],[7] Their minimum age was 20 years, and the maximum age was 42 years, with 71.9% of males and 28.1% of females.

Our study revealed that the term “AMS” was familiar to only about a third of our respondents. This is similar to findings from 3 medical schools in the United States where 40% of the students were familiar with this term. This may very well indicate the absence of the subject in the curriculum and invariably a lack of in-depth knowledge of AMS among respondents which is already the most widely accepted approach of resistance containment activities.[15],[16],[17]

In ABU, there are lecture series offered to all medical students on pharmacology and therapeutics (in 200 and 500 levels) as well as medical microbiology (400 level). This is usually the entry point of exposure to antimicrobials and rational use. These periods provide important opportunities to provide teaching on AMS as majority of the respondents did not have any research experience or knowledge about antimicrobials before entering medical school. This finding indicates that the perception our respondents have regarding AMS was mainly adopted from their lectures and clinical rotation in school. Thus, these findings are a reflection of the opinions of the 4th–6th-year medical students who have completed a major portion of their antimicrobial related portion of academic curriculum, i.e., pharmacology and therapeutics and microbiology. Thus, our study provides a better approximation of their current medical education, though potential recall bias on self-report could not be overcome (especially for the 600level students).

Majority of the respondents perceived that antimicrobials are overused nationally, compared to the hospital where they rotated. This is consistent with a study done in the US among medical students where majority (94%) of the respondents also perceived that antimicrobials were overused nationally.[6] It is also interesting to note that this finding is similar to that obtained in a US-based study of residents in training and more senior prescribers in which most physicians have agreed that “other doctors” overprescribe antimicrobials compared to “themselves” and that antimicrobials are overused nationally compared to their own practice.[18] Almost all our respondents correctly perceived that inappropriate use of antimicrobials can cause antimicrobial resistance, and majority perceived that better use of antimicrobials will reduce problems with antimicrobial resistance. This finding is positive and further indicates that our future prescribers will likely exercise more caution when prescribing antimicrobials due to their good perception on appropriate use. This is also consistent with other studies conducted in medicals schools in India and the United States where majority of the respondents also correctly perceived that antimicrobial resistance can be caused by inappropriate use of antimicrobials.[8],[12]

In our study, when respondents were asked to rate their education on AMS, majority agreed that it was very useful. They also clearly recognized the importance of AMS in their career as almost all strongly agreed/agreed that strong knowledge of antimicrobials was important in their medical career, and majority said that they would like more education on appropriate use of antimicrobials. Respondents' perception about AMS education is consistent with the findings from previous similar surveys conducted in medical schools in India, the United States, and Bangladesh which reported a good perception of medical students about the AMS education received in their respective schools.[6],[7],[8] More than half of our respondents think that medical schools should spend more time in the 4th year, teaching about the appropriate use of antimicrobials. This is because their clinical exposure begins from this level, and it would be a good method to link the teaching with the practice at an early stage. This finding is different from that of a study that was carried out in another US-based school where the students opined that more time should be spent in the 3rd year.[12]

The results of perception of the respondents on AMS further support a previous study which buttressed the urgent need to train our future prescribers about the rational use of antimicrobials. Medical schools in the UK and the USA have improved their curricula to address the teaching of AMS at the undergraduate level.

Our study is limited by the fact that all our respondents were from a single medical school, so the findings may not be a true reflection of the situation in the various other medical schools in Nigeria. Despite this limitation, this study suggests integrating AM pharmacology teaching with the clinical subjects to encourage and strengthen AMS education. The strengths of our study lie in the fact that our survey was voluntary, and the respondents were not allowed to take any assistance for filling the questionnaires, so the actual perception of the participants was collected.

  Conclusion and Recommendation Top

Our study revealed a good perception of AMS among the respondents. There is also a general recognition of the importance of cautious antibiotic use, and the students would like more improved instruction on how to make rational use of antimicrobials. This study prompts the need for introduction of certain interventions, for example, interactive sessions and clinical case-based learning with special emphasis on the irrational prescribing practices in which AM is not required or can be safely delayed for some time. Such education should be introduced in the 4th year of the curriculum itself, as it has the tendency to make our future prescribers better prepared for appropriate use of antimicrobials.

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Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. The evolving threat of antimicrobial resistance: Options for action. World Health Organization. 2012. p. 1-119 https://apps.who.int/iris/handle/10665/44812. [Accessed 2020 Oct 11].  Back to cited text no. 1
Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices. Virulence 2013;4:192-202.  Back to cited text no. 2
Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159-77.  Back to cited text no. 3
New Antimicrobialstewardship Standard. Joint Commission Perspectives. Vol. 26. New Antimicrobialstewardship Standard; 2016.  Back to cited text no. 4
Adebayo AM, Onadeko MO. Knowledge of school health program among public primary school teachers in Oyo state, South-Western Nigeria: A rural-urban comparative study. Afr J Reprod Health 2015;19:55-60.  Back to cited text no. 5
Abbo LM, Cosgrove SE, Pottinger PS, Pereyra M, Sinkowitz-Cochran R, Srinivasan A, et al. Medical students' perceptions and knowledge about antimicrobial stewardship: How are we educating our future prescribers? Clin Infect Dis 2013;57:631-8.  Back to cited text no. 6
Ferdoush J, Parveen K, Ata M, Reza FH, Rahman MS. Knowledge, perception and preparedness of future prescribers about antimicrobial stewardship. Bangladesh J Pharmacol. 2016;11:928-34.  Back to cited text no. 7
Sharma K, Jain P, Sharma A. Knowledge, attitude and perception of medical and dental undergraduates about antimicrobial stewardship. Indian J Pharmacol 2015;47:676-9.  Back to cited text no. 8
[PUBMED]  [Full text]  
MacDougall C, Polk RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev 2005;18:638-56.  Back to cited text no. 9
Ten years: The First Decade of Ahmadu Bello University, October 1962 October 1972, and history of Ahmadu Bello University. Zaria: Ahmadu Bello University Press; 1972.  Back to cited text no. 10
Singha P. Introductory text on biostatistics. 3rd ed.. Zaria: Abdullahi Bello Dabo Investment Limited; 2002. p. 205.  Back to cited text no. 11
Minen MT, Duquaine D, Marx MA, Weiss D. A survey of knowledge, attitudes, and beliefs of medical students concerning antimicrobial use and resistance. Microb Drug Resist 2010;16:285-9.  Back to cited text no. 12
Yang K, Wu D, Tan F, Shi S, Guo X, Min Q, et al. Attitude and perception regarding antimicrobial use and resistance among medical students in central China. Springerplus 2016;5:177-9.  Back to cited text no. 13
Likert R. A technique of measurement of attitudes. Arch Psychol 1932;140:1-55.  Back to cited text no. 14
Rahman MS. Changes required in pharmacotherapy teaching to ensure rational use of drugs. Bangladesh J Physiol Pharmacol 1995;11:38-9.  Back to cited text no. 15
Rahman MS, Huda S. Antimicrobial resistance and related issues: An overview of Bangladesh situation. Bangladesh J Pharmacol 2014;9:218-24.  Back to cited text no. 16
Centers for Disease Control and Prevention (CDC). CDC's campaign to prevent antimicrobial resistance in health-care settings. MMWR Morb Mortal Wkly Rep 2002;51:343.  Back to cited text no. 17
Abbo L, Sinkowitz-Cochran R, Smith L, Ariza-Heredia E, Gómez-Marín O, Srinivasan A, et al. Faculty and resident physicians' attitudes, perceptions, and knowledge about antimicrobial use and resistance. Infect Control Hosp Epidemiol 2011;32:714-8.  Back to cited text no. 18


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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